Civil Commitment - the American Experience

Article excerpt

Abstract: The evolution of U.S. civil commitment law needs to be understood within the context of changes in psychiatry and medicine, as well as larger social policy and economic changes. American civil commitment law has reflected the swinging pendulum of social attitudes towards civil commitment, oscillating between more and less restriction for both procedural and substantive standards. These standards have evolved from a "need for treatment" approach to a "dangerousness" rationale, and now may be moving to a position in which these justifications are combined, particularly in the context of involuntary outpatient commitment. Civil commitment in the United States has been shaped by multiple factors, including sensitivity to civil rights, public perception of psychiatry, availability of resources, and larger economic pressures. We suggest that current American commitment practice is influenced more by economic factors and social perceptions of mental illness than by changing legal standards.

Introduction

Involuntary civil commitment is often considered the primary intersection of psychiatry and law, and is typically one of the most publicly visible and contentious roles of psychiatrists within the larger society. In the United States, the legal struggles and changes in the process of civil commitment over the past 200 years reflect social ambivalence about the extent to which an individual's right to liberty can be restricted for the ostensible sake of protecting his interests or the interests of others (1). The evolution of U.S. civil commitment law needs to be understood within the context of changes in psychiatry and medicine, as well as larger social policy and economic changes. American civil commitment law has reflected the swinging pendulum of social attitudes towards civil commitment, oscillating between more and less restriction for both procedural and substantive standards. As Israeli psychiatrists, jurists and policy makers consider their own civil commitment laws, it may be helpful to consider the American experience (2, 3).

In this article, we briefly trace the historical evolution of civil commitment in the United States, describe some of the past and current controversies, reflect on the empirical data relevant to these processes, and offer analysis and perspective that may inform other nations working to improve their own civil commitment laws (4).

History

In Colonial times (i.e., pre-1776) and the early years of the United States, there was little formal legal regulation of the care of the mentally ill - likely due in part to the few options for treatment or institutional care (5). Mentally ill persons who could not care for themselves and lacked family care and support were typically ignored or managed in jails or almshouses for the poor. This approach had no real therapeutic aspects, but served purely as containment or punishment. From a social perspective, the practices were driven largely by the interests of public safety (the "police power" of the state), with little consideration of treatment or the rights and needs of mentally ill persons. Conditions in jails and almshouses were universally poor, with only basic sustenance in typically filthy settings, invariably mixing the mentally ill with criminals, vagrants, the retarded, the senile, and other social outcasts.

As jails and almshouses became crowded with mentally ill persons, there were some early efforts to develop private psychiatric units and hospitals, sometimes with public funds, albeit with little legal regulation. The first psychiatric admission in the colonies occurred in Philadelphia in 1752; by the early decades of the 19th century, a few small private and public facilities had developed across the states. Admissions were involuntary ("insane" persons were considered by definition to be unable to recognize their own interests and make decisions about hospitalization), typically initiated by family or friends, and the length of stay was linked to ongoing private financial support. …